How to File A Health Insurance Appeal

A problem, we who have lymphedema often face are denials from insurance companies.
At this time, there is no uniform national standard for the treatment of our condition. Many insurance companies will pay for therapy, but not compression garments or equipment. Others may give you trouble with needed diagnostics tests and/or present problems when it comes to treating complications. When you plan any treatment, whether your have leg_lymphedema or arm_lymphedema, you will want to study this important page.

If you are denied coverage, don't just accept that denial. You can and should appeal any insurance company decision you disagree with.

This section will provide information on how to appeal, the steps, necessary documentation and links for further assistance.

Wanted to especially thanks Tina for providing several top notch samples of appeal letters!!!

Also, wanted to share an except from a letter one of our members who is a therapist sent regarding insurance denials.

Also Pat, one thing people can do that most don't know about, is if the decision to treat is made by anyone who is not a licensed physician they can file a complaint with their local medical Board. Anytime someone changes doctor's orders or denies treatment that is called “Practicing Medicine without a license”.

If the decision to deny is made by a licensed physician, then it may be “diagnosing and/or practicing medicine without examining the patient”.

We have had success with getting approvals going that direction. I have a letter from the Nevada Board's attorney that outlines how that is illegal in this state, and believe me, I use the heck out of it. I have had two denials recently that were ridiculous. One stated denial was due to the patient not elevating enough. The other was due to patient not trying pool therapy as a conservative method of treatment. I have alos had several stating they did not agree with the diagnosis of lymphedema and believed the patient was just obese. I faxed that letter and had approvals within a few hours

In addition

A consumer can also file a complaint with their state's Attorney General alledging consumer fraud. If they are paying for insurance, and treatment is avialable under their policy, (whether it be physical therapy or Durable Medical Equipment, which all modalities of external compression fall under that category), then they have the right to obtain what the policy allows. If they do not, they can also go at it from the “attempt to defraud consumer by making inappropriate denial for coverage” - “breach of contract”, approach. They are going to want to see that the insured went through the insurance company's internal appeals process first though.

Tips To Writing Winning Appeals

Strategy to Reverse Denials

Step 1: Appeal Timely

Industry experts estimate that more than 70% of denials can be overturned. Despite that encouraging statistic, the greatest challenge most medical billing professionals face is timely appeal submission. Medicare appeals must be filed within 120 days of the claim decision; most commercial insurers require appeals within 180 days from the denial. Due to the sheer volume of claims most offices file, deadlines often pass before action is taken. If the appeal is filed late, the likelihood of success is significantly reduced. In order to meet appeal deadlines consistently, medical offices must have an appeal letter database where letters can be selected and quickly customized for any type of appeal.

Attempting to provide a detailed Level appeal is often a stumbling block to timely appeal submission. AppealLettersOnline.com has developed a collection of appeal letters to allow you to appeal on time and in a professional manner designed to overturn the denial or, in the minimum, demand a full disclosure regarding the basis of the decision.

Step 2: Appeal Twice

Most denials require two appeals for two reasons: first, insurance carriers do not always provide credentialed professionals for the initial review and second, insurance carriers often provide details in the Level I appeal response which may require further discussion. Level I appeal responses should be scrutinized for legal and contractual compliance. Some of the potential questions you should ask include:

Has the insurer provided the internal rules, guidelines or review criteria applicable to the denial? If not, is the carrier in compliance with potentially applicable denial disclosure laws?

If provided, does the internal rules, guidelines or review criteria cited by the insurance carrier actually apply to the treatment in question? Do the internal rules, guidelines or review criteria conflict with your internal quality care standards?

Has the insurer provided review by a credentialed professional familiar with the type of treatment and has that credentialed reviewer suggested appropriate alternative care which has equal likelihood of efficacy?

If the appeal involves a question of medical coding, has the insurer provided review by licensed coder familiar with the type of treatment?

If the appeal involves a managed care contract or fee schedule, is the most current contract or fee schedule being utilized?

AppealLettersOnline.com has numerous appeal letters discussing all of the above aspect of claim review. Level II appeals should address all details regarding the justification for payment and should also address the shortcoming or inapplicability of the information cited in the Level I appeal response. Finally, citing applicable regulatory information in appeal letters assures you that the appeal will also be considered from a compliance standpoint.

AppealLettersOnline.com has more than 1500 appeal letters which cite state and federal claim processing mandates to assist you with generating Level II appeals.

Step 3: Cite Compliance Issues In Appeals

Perhaps most challenging can be the necessity of citing compliance issues in your appeal and AppealLettersOnline.com is the only resource to present you with such information in a usable format. Compliance obligations are the most compelling aspect of your appeal and are likely to get the attention of the appeal claim reviewer. It is critical to your success to reference a carrier’s legal and contractual duties in regards to claim review.

A wide range of claim processing laws and regulations may apply. AppealLettersOnline.com has letters citing state and federal mandates which dictate mandatory coverage for certain procedures and outline consumer protections in regards to managed care.
Finally, if compliance issues are not fully addressed in the carrier response to the appeal, you may be able to elevate the appeal to a higher authority for review and we have abundant information regarding such efforts. Third level efforts may include the following options depending on the type of coverage and type of denial:

Requesting an independent review through the fiduciary (often the employer) on ERISA claims

Requesting an executive level or legal review with the insurance company on matters of contract compliance

Effective Level III appeals require careful review of the claim to determine jurisdiction. Personnel responsible for Level III appeals should have an opportunity for training on state and federal claim processing regulations and how they apply to medical claims. Further, Level III appeals must often contain all the information to support the claim including medical records and even patient account, precertification and verification of benefits information depending on the type of denial.

Appealing Health Insurance Denials

by Heidi Frey

Getting your medical expenses covered by your health plan can be frustrating, but a little knowledge can go a long way

The Basics

You can start by checking the following on your health plan:

Do you need a referral from your primary care physician in order to see a specialist?

Does the plan require prior authorization for a planned surgery or hospital stay?

Do you have to select a physician from a network for the charges to be fully cored?

What does your plan cover?

What does it limit or exclude?

Don’t Be Stopped By Denials

One should consider appealing if:

The treatment isn’t a covered benefit, but you think the health plan should make an exception for you, or

You have support from your physician that the treatment is “medically necessary,” or

The treatment is deemed by the insurance company to be experimental or investigational.

Call the company that issued the denial, armed with a file of your medical and insurance information, including your benefit plan and summary.
A customer service representative can’t overturn your denial, so ask to speak with a supervisor.

Making a Formal Appeal

Every managed care organization is required by law to have an appeal process.
Although an appeal process isn’t perfect, it’s much less of a financial and emotional burden than litigation. And your contract with the health plan may prohibit you from filing a lawsuit before filing an appeal.

When formally appealing

Your health problems and treatment history
How you have exhausted all other reasonable alternatives
Physician recommendations

Why you are an ideal candidate
What will happen if treatment is not approved
Support letters from your physicians
Quotes from the benefit plan if it contains helpful language
Medical records that support your position.

Enlist your doctor’s help. Your doctor willing to advocate for you.
Track relevant dates to ensure that your complaint is moving forward expeditiously.
Be prepared to spend a lot of time on the phone.
Keep a record of all communications, including the date and time of your conversation, the full name and title of the person with whom you spoke, and a summary of what was discussed.

Getting Help

Your state Department of Insurance (DOI) has a wealth of information, including your rights regarding health insurance, the appeals process, whom to contact regarding an appeal and a general timeline for an appeal.

You should be able to locate your state’s DOI in the White Pages’ state government section under “Insurance” or “Regulatory Agencies.” Your state government’s home page should have a link to the DOI.

If you have questions regarding the mechanics of the appeals process:

If you’re in a self-insured plan, which means that your employer has direct responsibility for medical costs, you should contact someone in your employer’s human resources department for more information.

If you’re in a Medicaid managed care plan, you may have special rights in the appeal process and you should contact the State Ombudsman or Medicaid customer service.

If you’re in a commercial plan, which means that the managed care organization has direct responsibility for medical costs, the appeals process is outlined in your policy and follows state laws.

What’s Next

If the cost of the denial is enough to offset legal fees, it may be best for you to speak with an attorney who has experience with health care coverage and benefit denials.

I am writing to appeal [Medical Group or HMO] decision to deny authorization for [name of treatment and/or diagnostic test requested] for me. The [Medical Group or HMO] has denied coverage for [Name of treatment and/or diagnostic test requested] as “not a covered benefit” under my plan. I believe [Name of treatment and/or diagnostic test requested] is medically necessary to [treat or diagnose] my medical illness and is a covered plan benefit. [Medical Group or HMO] should approve and authorize [Name of treatment and/or diagnostic test requested] in my case.

Failure to provide [IMMEDIATE TREATMENT OR REQUESTED TEST] for my illness envokes imminent and serious threat to my health. I am, therefore, requesting an expedited MD review of my appeal for BENEFIT coverage. Please provide me with a decision as soon as possible and no later than five days from the date of this appeal.

[your Medical Group or HMO] covers medically necessary services that are not specifically excluded, in addition to services specifically included under the plan terms. [your Medical Group or HMO] definition of medically necessary is found on [page #] of my [Evidence of Coverage or Summary Plan Description]. Medically necessary is defined as: [insert descriptions from handbook]

[Name of treatment and/or diagnostic test requested], for addressing my condition, falls within this definition. The plan excludes treatments. Procedures and diagnostic tests listed on [page #] of my [Evidence of Coverage or Summary Plan Description]. [Name of treatment and/or diagnostic test requested] is not listed as an exclusion or limitation under my health plan coverage.

[Name of treatment and/or diagnostic test requested] is recommended for my medical condition by [physician/specialist in Medical Group or HMO] and is considered medically necessary to [treat or diagnose] my condition. In fact, [Name of treatment and/or diagnostic test requested] is within the standard of sound clinical practice. [your Medical Group or HMO] failure to provide [Name of treatment and/or diagnostic test requested] violates our states “mandated benefit laws”.

I am suffering from [name of condition OR “an undiagnosed condition”] and it affects my ability to conduct activities of daily living. I have previously received [types of other treatments you have tried AND/OR diagnostic tests you have undergone, if any] to [address AND/OR diagnose] my condition. However, my health problems have not been resolved. [Name of treatment and/or diagnostic test requested], I will continue to experience these and worse [problems]. If left [untreated or undiagnosed], my condition may require even more complex and costly treatment in the future. I have included documentation of my medical condition, and information supporting the medical necessity of [Name of treatment and/or diagnostic test requested], with this letter. Please let me know if any additional information will be helpful to my request. I can be reached at [telephone number].

I am writing to request [Medical Group or HMO] the authorization to obtain services outside contracted area for my medical care. Specifically, I request the authorization for access to [name of medical center, hospital, or institution] for the treatment of my illness. My current [Medical Group or HMO] physician [name of your doctor] has diagnosed me to have [name of illness] and is suggesting immediate procedural treatment. I am convinced that [name of medical center, hospital, or institution] will provide me the highest quality medical care for my condition and it is therefore medically necessary that I obtain authorization as soon as possible. I understand that [Medical Group or HMO] maintains contracts with [name of medical center, hospital, or institution]. Please immediately change my primary care provider and Specialist to a [Medical Group or HMO] physician that has access to[ name of medical center, hospital, or institution]. [Medical Group or HMO] should allow this immediate request to obtain services outside contracted area.

Failure to provide ME IMMEDIATE ACCESS TO [NAME OF MEDICAL CENTER,HOSPITAL, OR INSTITUTION] for my illness envokes imminent and serious threat to my health. I am, therefore, requesting an expedited MD review of my appeal for APPROVAL OF MY REQUEST. Please provide me with a decision as soon as possible and no later than three days from the date of this appeal.

I am attaching documentation of my medical condition, and information supporting the medical necessity of my request for services outside contracted area. Please let me know if any additional information will be helpful to my request for coverage. I can be reached at [phone #].

I am writing to request [Medical Group or HMO] to authorize my medical care be administered by a Specialist. [Medical Group or HMO] has delayed or denied my doctor’s referral request for me to see a [type of Specialist, name of Specialists]. My primary care physician [name of your doctor] has diagnosed me to have [name of illness] and it is medically necessary that I see a Specialist as soon as possible. I further request that this specialist [type of Specialist, name of Specialists] be given adequate opportunity to oversee my care until such time as to the resolution of my illness . [Medical Group or HMO] should allow my immediate request to see a specialist..

Failure to provide ME THE OPPORTUNITY TO SEEK THE TREATMENT OF A SPECIALIST for my illness envokes imminent and serious threat to my health. I am, therefore, requesting an expedited MD review of my appeal for APPROVAL OF MY SPECIALIST REQUEST. Please provide me with a decision as soon as possible and no later than five days from the date of this appeal.

I am attaching documentation of my medical condition, and information supporting the medical necessity of my Specialist referral. Please let me know if any additional information will be helpful to my request for coverage. I can be reached at [phone #].

I am writing to request [Medical Group or HMO] the authorization to obtain a Second Opinion referral for my medical care. In order to assure the objectivity of this appointment, I request to see a [type of Specialist] from outside the [Medical Group or HMO] organization. My current [Medical Group or HMO] physician [name of your doctor] has diagnosed me to have [name of illness] and is suggesting procedural treatment. It is therefore medically necessary that I obtain a Specialist Second Opinion as soon as possible. I further request the opportunity to suggest the name of this specialist [type of Specialist, name of Specialists]. [Medical Group or HMO] should allow my immediate request for a second opinion.

Failure to provide ME THE OPPORTUNITY TO SEEK AN OBJECTIVE SPECIALIST SECOND OPINION for my illness envokes imminent and serious threat to my health. I am, therefore, requesting an expedited MD review of my appeal for APPROVAL OF MY SECOND OPINION REQUEST. Please provide me with a decision as soon as possible and no later than five days from the date of this appeal.

I am attaching documentation of my medical condition, and information supporting the medical necessity of my Second Opinion referral request. Please let me know if any additional information will be helpful to my request for coverage. I can be reached at [phone #].

Fighting health-insurance claim denials

One of these days, you might have to battle your health insurance company over a denial of coverage.

Of course, most people would rather skip the fight, and there are steps you can take to avoid health insurance denials before they occur.

And if that doesn't work, there are steps you can take to fight them once they do.
The key is organization – having all your paperwork in order, taking detailed notes of your interactions with everyone in the process and understanding your coverage.

Knowledge – your best weapon

Information is power, and this is never truer than when battling a health care system. The winner may be the side with the better-organized, more-detailed information.
Some experts feel that legislation is tilting the regulatory environment in the patients' favor.
“The environment is becoming more consumer friendly as more states and health plans adopt independent review processes,” says Larry Gelb, president and CEO of CareCounsel LLC, a health care advocacy group.

Four basic Steps in an Appeal for Lymphedema

Use the same logic that I use for Medicare appeals. The steps and logic goes
along as follows:

You must make clear to your insurance company the following:

Lymphedema is a medical condition requiring medical treatment.

There is a diagnostic code for primary lymphedema. It is NOT a cosmetic issue. Untreated
lymphedema puts you at risk for serious infections, it is disabling and it is
chronic. Get a letter from your physician describing your diagnosis (with
code), the recommended treatment protocols (MLD, compression with bamdages and
garments), special exercises, and skin care. (See below, Documentation
Requirements)

You have the right, after being diagnosed with lymphedema, to an initial course of MLD

by a trained and certified therapist. During this course you will
be bandaged by the therapist, who will teach you how to continue a less
intense MLD and bandaging at home, how to exercise and how to care for your
skin.

Although Medicare does not provide compression bandages and garments, I have
made a successful appeal on behalf of my wife that resulted in the provision
of two bandage sets and two garments twice a year to ALL lymphedema patients of
Kaiser Permanente HMO in California. The determination by the State's medical
consultant was that that the garments and bandages were a part of the current
standard of treatment of lymphedema and that without them the provider was in
violation of the State law that mandated treatment of lymphedema.

Furthermore, I have established in one Medicare appeal that these compression
bandages and garments fit the definition of “prosthetic devices” as defined in the
Social Security Act.

The general mechanics for the appeal

was documented very well in the following summary:

Information on how to appeal to your insurance company if a claim was denied
(source: Aventis Living With It: A support program for women with recurrent
BC through YSC July 2003 Meeting Minutes)

Call your carrier and find out why your claim was turned down for payment.
It may be as simple as a claim being input improperly. However, if it is not
merely a clerical error and you feel that something should be covered, you
have the right to an appeal.

If the matter is not merely a clerical error and you feel that something
should be covered, you can appeal the decision. Sometimes all it takes is a
simple request to have your claim reviewed over the phone. However if that
isn't enough, consider taking the following, more formal steps for an appeal:

Read your policy or benefits booklet to ensure that there is nothing in the
plan that specifically excludes the type of care you received or are scheduled
to receive.

Write a letter to the insurance company. Usually it should be addressed to
the person who signed the letter notifying you that your procedure or
treatment would not be covered. Explain why you feel the procedure should be
reimbursed and ask that your request be reviewed by a physician with the same
specialty as the doctor who ordered the treatment or procedure thatâ€™s in
question.

Send a copy of the denial notification you received along with your letter.
The letter itself should ask why coverage is being denied or paid at a reduced
level. Also, request a copy of the specific statement â€“ drawn from the
policy or from the benefits booklet â€“ that explains why your coverage is
limited or denied.

If you receive an explanation that states your policy does not cover this procedure,
then you have the right to see that policy language in writing. Make certain
that these policy restrictions were in place when you were originally covered
by your contract with the health plan and started paying premiums. If the
restrictions were not initially in place, you may have the right to coverage
under the insurance laws of your state (see www.healthinsuranceinfo.net for
state
laws).

You can consider sending a duplicate mailing of your appeal letter to the
insurance commissioner of your home state. You can get this contact info from
the above mentioned web site. You should include a brief cover letter
explaining the trouble you are having and asking for assistance.

If you feel like you are not getting anywhere, you might want to ask your
insurance company about case management. Almost all national insurance
companies have case managers who can act as a liaison between you and your carrier, and
help coordinate payments to your various providers. Case managers are
professionals and often registered nurses.

Documentation Requirements

The medical record documentation maintained by the provider must clearly
document the medical necessity of the services being performed.

This document would need to include the following:

a physician documented diagnosis of lymphedema
a statement as to the ability of the patient/patient caregiver to
follow through with the continuation of treatment on a long term home
treatment plan.

the medical necessity of each treatment
history and physical which addresses the cause of the lymphedema
and any prior treatment. It must also address the symptoms which necessitate
treatment.

measurement of body part/extremity prior to treatment
â€¢ a report showing the progress of the therapy which should contain
measurements showing a reduction in size of the extremity. This should also
address the response of the patient/patient caregiver to the education and their
understanding and ability to take on some of the responsibilities of the
treatment. This progress report must also address the expected outcome of the
treatment as well as the expected duration of treatment.

[added by R. Weiss, not in LCD] prognosis with treatment and
without treatment, specifically relating undertreatment of lymphedema with an
increased risk of infection, disability and lymphangiosarcoma.

Center for Patient Advocacy

National Insurance Consumer Helpline

A general information source for all types of insurance-related issues, including life and health insurance

800-942-4242

Patient Advocacy Coalition

303-744-7667

The Coalition focuses on assisting people in the appeals process when an insurance company has denied coverage for medical treatments. They provide free advice and support on how to present a comprehensive and compelling case

Patient Advocate Foundation (PAF)

800-532-5274

help@patientadvocate.org

This organization serves as an active liaison between the patient and their insurer, employer and/or creditors to resolve insurance, job discrimination and/or debt crisis matters relative to their diagnosis

Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.

Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

MEN WITH LYMPHEDEMA

If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.

All About Lymphangiectasia

Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.

Lymphatic Disorders Support Group @ Yahoo Groups

While we have a number of support groups for lymphedema… there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.